Chapter 6 Part B: Post-event.
Screening individuals
for vaccination during a smallpox emergency.
Relative contraindications, with Dr. Brett Petersen.
Relative contraindications to ACAM2000
in a post-event setting include individuals
with atopic dermatitis or eczema, HIV infection
with CD4 counts of 50 to 199 cells per cubic millimeter,
and other immunocompromised states,
which include solid organ transplant recipients
within 3 months of transplantation,
bone marrow transplant recipients during the 4
to 24 month time period after transplant,
transplant recipients
with active graft-versus-host disease,
individuals receiving immuno-suppression therapies
such as alkylating agents, antimetabolites, radiation,
tumor necrosis factor inhibitors,
and high-dose corticosteroids, and individuals
with a past history of allergy to ACAM2000
or other replication-competent smallpox vaccines
or an ACAM2000 vaccine component.
The decision to vaccinate with ACAM2000 will be based
on a risk-benefit assessment including the risk
for smallpox infection.
ACAM2000 is recommended for individuals
with atopic dermatitis who have been exposed to smallpox
and for individuals who have a history of being vaccinated
with a replication-competent smallpox vaccine
without any vaccine-related adverse events,
regardless of their smallpox exposure status during
the emergency.
However, if the individual is at high-risk for smallpox
but without a known smallpox virus exposure
and does not have a history of prior smallpox vaccination,
then vaccination
with a replication-deficient smallpox vaccine
such as Imvamune is recommended if the vaccine is available
and authorized for use by the Food and Drug Administration.
Recommendations for individuals
with HIV infection differ depending
on their CD4 cell counts at the time of the smallpox emergency.
Individuals with HIV infection and CD4 cell counts of greater
than 200 cells per cubic millimeter who are exposed
to smallpox virus or at high-risk
for smallpox infection should be vaccinated with ACAM2000.
Individuals with HIV infection and CD4 cell counts of 50
to 199 cells per cubic millimeter who are exposed
to smallpox virus should be vaccinated with ACAM2000.
But individuals with HIV infection and CD4 cell counts
of 50 to 199 cells per cubic millimeter who are at high-risk
for smallpox without a known smallpox virus exposure should
be vaccinated with Imvamune.
Individuals with HIV infection and CD4 cell counts of less
than 50 cells per cubic millimeter may not benefit
from smallpox vaccination
and should follow the recommendations under
"Individuals with Severe Immunodeficiency."
ACAM2000 is recommended for individuals with diseases
or other conditions that cause immunodeficiency
or immunosuppression who have been exposed
to smallpox virus unless they have severe immunodeficiency
and are not expected to benefit from vaccination.
But immunocompromised individuals such as those
with a recent solid organ transplant,
recent bone marrow recipients, transplant recipients
with active graft-versus-host disease, and persons currently
on immunosuppressive therapies who are at high-risk
for smallpox infection without a known exposure
to smallpox should be vaccinated with Imvamune,
if the vaccine is available and authorized for use by the Food
and Drug Administration.
Although other chronic conditions
such as heart disease, diabetes mellitus,
and arthritis may have some component of immunosuppression,
the benefits of vaccination
with ACAM2000 during a smallpox emergency likely outweigh the
risk for a serious adverse event
because of the relatively lower degree of immunosuppression
with these conditions.
Similarly, ACAM2000 is preferred to Imvamune for persons
with other immunocompromising conditions such as complement
or phagocytic deficiencies
because these individuals are likely
to produce sufficient immune responses to vaccination
with no known increased risk for serious adverse events.
Prior to vaccination and regardless
of a smallpox virus exposure, individuals suspected
of having a severe allergy
to smallpox vaccination should be counseled on the risks
of a severe allergic reaction.
It is recommended that these individuals be vaccinated
in a facility capable
of treating an anaphylactic reaction.
Reconstituted ACAM2000 vaccine contains trace amounts
of the antibiotics polymyxin B and neomycin.
It also contains phenol as a preservative.
Individuals exposed to smallpox
who have had a severe allergic reaction to a previous dose
of smallpox vaccine other
than ACAM2000 should still receive ACAM2000.
Individuals exposed to smallpox virus who have severe allergies
to any of the ACAM2000 components or to a previous dose
of ACAM2000 should be vaccinated with APSV, if available.
If APSV is not available, then ACAM2000 should be given.
For individuals at high-risk for smallpox infection
without a known smallpox virus exposure,
they should be vaccinated with any available smallpox vaccine
that does not contain the vaccine strain
or vaccine component associated with severe allergy.
If the smallpox vaccine
that does not contain the vaccine strain
or vaccine component associated
with the severe allergy is unavailable,
then the individual should be offered vaccination
with any available smallpox vaccine.